Hirsutism is characterised by excess body hair in a typically male
distribution. The hair is pigmented and thick. It may be particularly
obvious when it is on the moustache or beard areas. The other common sites
are the chest, abdomen, thighs and back. Pubic hair growth may extend upward
from the usual bikini-line to the middle of the abdomen (umbilicus) (Figure
8.1). For a woman to be hirsute is understandably embarassing.

Virilism is more extensive than hirsutism, with additional evidence of
masculinisation. There may be acne, oily skin, temporal scalp baldness,
enlargement of the clitoris, voice deepening, breast size reduction, and
irregular or absent periods. Occasionally, there may be increased libido and
aggression.

Virilization is a relatively uncommon feature of hyperandrogenism, and its
presence often suggests an androgen-producing tumor.

Each hair is formed from a hair follicle in the skin and each follicle lives
for about three years. A hair consists of a column of dead cells derived from
the living hair follicle. There is a central medulla, which contains the
coloured melanin, and a hard external cuticle. Sebaceous glands are connected to
the follicle. The sebaceous glands and the hair follicles are sensitive to the
circulating androgens (masculinising sex hormones
Q 2. 9). Acne
and excess body hair may be associated with increased levels of androgens.

Our skin is covered by hair follicles but those in the typical male
distribution are sensitive to androgens which increase the hair production, and
oestrogens (female sex hormones) which decrease it. These sex hormones are
carried in the blood on a protein called sex hormone binding globulin (SHBG).
Androgens decrease the amount of circulating SHBG and oestrogens increase the
SHBG. If there is less SHBG, more of the androgen is free (unbound to protein)
and available to act on the hair follicles. (SHBG).

In one survey 15% of women thought they had excess body hair although doctors
found objective evidence of hirsutism in only 7%. There is a variation in normal
hair production between ethnic groups. One study suggests that the incidence of
hirsutism in the USA and Europe is about 10%A study in Lithuania found that only 60% of patients complaining of hirsutism
were clinically hirsute.

Hormone secreting tumours of an ovary or an adrenal gland causing hirsutism
are extremely uncommon.

The adrenogenital syndrome (congenital adrenal hyperplasia) usually
presents in early life. The adrenal glands produce a variety of hormones. When
they are unable to produce cortisol, the pituitary gland produces increased
amounts of the hormone ACTH and this results in an increased production of
androgens. If the cortisol synthesis is only partly deficient the adrenogenital
syndrome may not be apparent during childhood but presents later in life with
hirsutism or virilism. Some medicines can cause hirsutism and virilism and there
are some rare diseases, such as porphyria, which are associated with hirsutism.

The story and examination findings may suggest the cause. Investigations
including blood tests to determine hormone levels, and ultrasound are usually
required. A simple flowchart (Figure
8.2) indicates the basic investigations and how they lead to a diagnosis.

Ultrasound examination and blood tests help to determine the cause.

If you have polycystic ovaries, ultrasound examination will usually
demonstrate the typical picture.

Tumours of an ovary or adrenal gland are uncommon but could be shown by the
ultrasound examination.

An elevated LH in the blood during the first eight days of the menstrual
cycle suggests polycystic ovary syndrome unless the FSH is also high suggesting
the menopause.

Testosterone may be slightly elevated in polycystic ovary syndrome or higher
if there is a hormone secreting tumour.

Sometimes the tests demonstrate no obvious abnormality and we assume that the
skin is particularly sensitive to androgens; this may be a familial problem.

Many patients presenting with hirsutism are understandably anxious to exclude
a major medical problem. Reassurance that investigations are normal or show just
a minor imbalance may be all that they are seeking.

Usually clinical assessment and investigation will identify a cause but this
is not always the case. This idiopathic hirsutism occurs in about 5% of patients
with hirsutism.

Fat tissue is involved in altering some sex steroids to androgens. If you are
overweight, this will tend to increase body hair production. Going on a diet and
increasing your exercise should help you lose some of the unwanted hair and also
help your general health.

Insulin resistance is common in polycystic ovary syndrome and this may be
associated with weight gain, which in turn increases hirsutism. A diet designed
to reduce weight may reverse this trend.

Combined oral contraceptive pills, and in particular one containing the
anti-androgen cyproterone acetate (Dianette - Schering) are the most popular
treatments for hirsutism. The new pill -
Yasmin- is particularly
helpful.

inhibit overproduction of androgens.

Steroids such as dexamethasone may be used if there is evidence of congenital
adrenal hyperplasia. There is some evidence that a small dose of steroids can be
an effective treatment when no obvious cause can be found.

Suppression of ovarian hormone production with GnRH analogues (gonadotrophins) is
expensive and they can only be used by themselves for short spells.

Combinations of GnRH and add-back hormone replacement therapy (HRT-Add-Back)
may have an occasional place.

increase SHBG

Combined oral contraceptive pill.

block androgen receptor sites.

Cyproterone acetate (15)

increase sensitivity to insulin.

Metformin: There had been accumulating evidence that the clinical
manifestations, including hirsutism, associated with PCOS can be related to
insulin resistance (PCOS cause).
Recent controlled research studies have shown disappointing results. Metformin
is a drug that increases insulin sensitivity and it has been used from the 1950s
in the management of diabetes. Recent studies have demonstrated that metformin
may be of value in the treatment of hirsutism associated with PCOS.

Patients often present with a combination of hirsutism and infertility.
Investigation to establish the cause is required. Several medical treatments for
hirsutism, such as the combined oral contraceptive, would clearly be
inappropriate when pregnancy is being contemplated. Metformin may have a place
in the treatment of PCOS associated hirsutism and anovulatory infertility.
Currently we recommend that the drug should be discontinued as soon as pregnancy
is confirmed.

A meta-analysis found a significant reduction in hirsutism for flutamide,
spironolactone, cyproterone acetate combined with an oral contraceptive,
thiazolidinediones, oral contraceptive pills (OCPs), finasteride and
metformin.

Eflornithine HCl (Vaniqa - Vaniqa is pronounced 'Vanika') 13.9% cream is the
first topical prescription treatment to be approved by the US FDA for the
reduction of unwanted facial hair in women. It irreversibly inhibits ornithine
decarboxylase (ODC), an enzyme that catalyzes the rate-limiting step for
follicular polyamine synthesis, which is necessary for hair growth. In clinical
trials eflornithine cream slowed the growth of unwanted facial hair in up to 60%
of women. Improvement occurs gradually over a period of 4-8 weeks or longer.
Most reported adverse reactions consisted of minor skin irritation.

Vaniqa is an enzyme inhibitor used topically to slow the growth of
unwanted facial hair in women. It does not remove hair. Re-growth of unwanted
hair can be dramatically slowed by the use of Vaniqa and in some cases, hair
becomes so weak, it barely grows at all. The hairs that do grow after continued
use of Vaniqa become considerably weakened which makes them finer and far less
noticeable than coarse thick or dark hair often associated with unwanted facial
hair in women.

Vaniqa is a cream that helps women to manage unwanted facial hair. It is the
first cream that is clinically proven to slow the growth of unwanted facial hair
in women. Vaniqa does not remove hair . Applying this fragrance-free cream
twice a day, every day, does not replace your current method of removal.
Instead, Vaniqa complements it, by slowing hair growth. You should continue
to use your current method of hair removal or treatment. Vaniqa is a
prescription drug for external use only.

Some medicines or medical conditions may interact with this medicine. Inform
your doctor or pharmacist of all prescription and over-the-counter medicine you
are taking including any facial or skin creams. Also, any other medical
conditions such as broken skin, sores on the face, allergies, or if you are
pregnant or breast-feeding should be indicated.

Vaniqa comes with a patient information leaflet. Apply a thin layer of Vaniqa
to the affected areas of the face and under the chin, at least 5 minutes after
hair removal (e.g., plucking, shaving). Rub in thoroughly. Do not wash the
treated area for at least 4 hours. Wait at least 8 hours between applications of
this medicine. Cosmetics or sunscreens may be applied after the Vaniqua has
dried. Store Vaniqa at room temperature (77 degrees F or 25 degrees C) in a
tightly-closed container, away from heat and light. Brief storage between 59 and
86 degrees F (15 and 30 degrees C) is permitted. Do not freeze. If you miss a
dose of this medicine, skip the missed dose and return to your regular dosing
schedule.

Vaniqa is not a depilatory agent. You will need to continue your routine
method of hair removal whilst using Vaniqa. You may not see improvement for the
first month of use.

Side effects of Vaniqa which may go away during treatment include: stinging,
burning, redness, tingling, rash of the skin or hair follicle infection (folliculitis).
Vaniqa cream does not have contact sensitising, photocontact allergic or
phototoxic properties. It can cause irritation under exaggerated conditions of
use. Eflornithine HCl 13.9% cream, therefore, has a favourable dermal safety
profile appropriate for a topical treatment to be applied routinely.

Higher dose cyproterone acetate may be considered. It is prescribed in a
'reverse-sequential dose regimen' when there is an inadequate response to
previous medication. Usually, progestogens are taken in the latter half of
cyclical oestrogen therapy, in HRT for example (HRT
and progestogen). Cyproterone acetate is stored in the fat tissues and when
it is administered late in the cycle there is a tendency for the period to be
delayed. Cyproterone acetate 50mg or 100mg is, therefore, given on the first 10
days of each course of the pill. When cyproterone acetate is given in
combination with the pill, it is likely to reduce hair growth, lighten the hair
colour, and decrease the hair thickness in hirsute areas. Your doctor may re
quest blood tests from time to time to check hormone levels and to ensure that
your chemistry is not being affected adversely.
Until recently, it was believed that cyproterone pills (Dianette) carried a
greater risk of being associated with thromboembolism. This no longer appears
valid.

Medical treatments for hirsutism are not rapidly effective, overnight
remedies. New hair follicles are developing all the time and each lasts for
about three years. In one study of hirsute patients, 10-20% of patients were
improving after six months and 90% were happy after 36 months. These treatments
only work whilst they are being taken. They do not cure the underlying
abnormality so that when treatment is discontinued the hirsutism may recur.

The commonest cause of hirsutism is polycystic ovary syndrome (PCOS). It has
been known for sixty years that removing part of these ovaries surgically (wedge
resection) can restore normal ovarian function.

Support groups offer companionship and information for people coping
with diseases or disabilities. Support groups may not be appropriate for
everyone, and some find that a support group actually adds to their stress
rather than relieving it.

Evaluation of the quality of Web sites is discussed in
(Q4.27).
You may find that several general women's health sites may help you (internet
information). The following are more specialised relevant Web sites:-

This page was last updated 19th April 2008

This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

Article Writing and Internet Marketing

David Viniker retired from active clinical practice in 2012. In 1999, he setup this website - www.2womenshealth.com - to provide detailed
information many of his patients requested. The website attracts thousands of visitors every day from around the world.Website optimisation (SEO) has became more than an active hobby.
If you would like advice on your website, please visit his website Keyword SEO PRO or email him on david@page1-on-google.com.
He now creates and modifies
websites for London
businesses to bring them to the
top
page of Google for targeted keywords. Top positioning depends on
the authority of your website and webpages. David writes articles on
subjects varying fromlife coaching in
Bedfordshire to
office cleaning
in central London. For those SMEs who undertake SEO for their
own websites, he offers SEO
Courses in North London and Essex.

The aim of this web site is to provide a general
guide and it is not intended as a substitute for a consultation
with an appropriate specialist in respect of individual care and
treatment.